Bezoar in Meckel's diverticulum: Case report and narrative review

Abstract

Introduction

Bezoars are a known cause of complications in Meckel's diverticulum. We present a case in which a bezoar in a Meckel's diverticulum resulted in intestinal obstruction. In addition, we conducted a narrative review to explore the association between Meckel's diverticulum and bezoars.

Case presentation

We present the case of a 22-year-old patient admitted for bowel obstruction persisting for three days and periumbilical tenderness. Abdominal CT tomography revealed a hyper dense circular structure with a diameter of 2 cm, small bowel distension of 41 mm, and free fluid. During surgical exploration, a Meckel diverticulum was found between the antimesenteric border of the small bowel and posterior wall of the umbilicus. The Meckel diverticulum was resected, and upon examination, it was found to contain a calcified phytobezoar. The postoperative course was uneventful.

Discussion

The clinical and paraclinical presentation of bezoars in Meckel's diverticulum is nonspecific and diagnosis remains challenging despite improved diagnostic modalities. The association between Meckel's diverticulum and bezoars is often identified during surgery, as it is difficult to diagnose using CT scans. The choice between laparoscopic and open surgery depends on the patient's situation.

Conclusion

Diagnosing a bezoar in a Meckel's diverticulum remains challenging. Treatment involves surgery, and the choice of surgical approach depends on the context.

Highlights

• •The association between bezoars and Meckel's diverticulum can occur without any psychiatric disorders.
• •This condition more often presents as intestinal obstruction but may also be asymptomatic and Physicians should consider this association when a foreign body does not progress on radiography.
• •There is no place for endoscopic treatment on this bezoar site.
• •Laparoscopy is highly useful for both diagnosis and treatment.
• •Phytobezoar are the most frequent type of bezoar associated with Meckel's diverticulum.

1. Introduction

The work has been reported in line with the SCARE criteria [1].

Meckel's diverticulum, a common form of persistent omphalomesenteric duct, occurs in approximately 2 % of the population [2]. Clinical manifestations can vary from simple abdominal pain to severe complications such as peritonitis and intestinal obstruction [3]. A bezoar is a concretion of indigestible foreign material in the gastrointestinal tract [4]. It can result from dietary habits, poor food digestion, overeating, gastrointestinal surgery, and psychiatric disorders [4,5]. Meckel's diverticulum and bezoar can both remain asymptomatic, although bezoar is known to be a precipitating factor for symptoms related to Meckel's diverticulum [2,6,7]. This report describes a case of a phytobezoar associated with Meckel's diverticulum that led to complications in the form of small bowel obstruction. A narrative review of this association was conducted following SCARE criteria [1].

2. Case report

We present the case of a 22-year-old patient who was admitted with periumbilical pain, constipation, and vomiting that lasted for 3 days. The patient had previously visited a community health center where they had received antibiotics and analgesics for 3 days. Physical examination revealed mild abdominal distension with periumbilical tenderness. The rectal examination yielded normal results. A complete blood count showed 8000 white blood cells per dL with 80 % neutrophils. Ultrasonography revealed minimal free fluid and small bowel distension. An abdominal CT scan showed a hyper-dense circular structure with a diameter of 2 cm, small bowel distension of 41 mm, and free fluid (Fig. 1, Fig. 2). Complicated small bowel obstruction due to a foreign body was suspected, leading to an exploratory midline laparotomy. During exploration, a Meckel diverticulum was found 50 cm from the ileocecal junction between the antimesenteric border of the small bowel and the posterior wall of the umbilicus, it was adherent to the umbilicus forming a band responsible of the obstruction (Fig. 3-A, B). The diverticulum was resected, and upon examination, it contained a calcified phytobezoar (Fig. 3-D). The postoperative course was uneventful, and the patient was discharged on the 5th day. Histological analysis confirmed a diagnosis without heterotopia or dysplasia.

Fig. 1.

Calcified ring (arrow) and peritoneal effusion (star) on CT of the abdomen.

Fig. 2.

Dilated loops and calcified ring on frontal reconstruction on CT of the abdomen.

Fig. 3.

Meckel diverticulum attached to the posterior wall of the umbilicus and bridge with the intestine (A and B). Site of the obstruction after realizing the obstruction and resection of the diverticulum (C), Meckel diverticulum with the calcified phytobezoar (D).

3. Discussion

A narrative review of the literature was conducted without any limitations in terms of time and language. The search engines used were PubMed, Google Scholar, and the African Journal Online (AJOL). The search terms included “Meckel diverticulum and bezoar” and “Meckel diverticulum and foreign body”. Only articles (case reports and case series) describing the association between a bezoar and Meckel's diverticulum were retained, with a focus on full-text articles. Additionally, a manual search of the references in the identified articles was performed to ensure that no relevant articles were omitted. SCARE criteria were used to evaluate each study [8].

In total, 37 articles were included, consisting of 34 clinical cases and 3 case series, amounting to 41 patients, including our case. Incomplete articles and articles lacking detailed clinical, radiological, and operative results were excluded. The parameters studied included age, sex, medical history, clinical presentation, imaging, preoperative diagnosis, surgical approach, and the nature of the bezoar. The results of various studies are detailed in Table 1.

Table 1.

Results.

References	Age (years)	Sex	Preoperative diagnosis	Imaging	Surgical route
Necattin Firat et al. [2]	34	W	Intestinal obstruction	X-RAY and CT	Open surgery
	35	M	Intestinal obstruction	X-RAY and CT	Open surgery
Peter J et al. [23]	34	M	Intestinal obstruction	CT	Laparoscopy
Marco Gasparella et al. [20]	12	M	Peritonitis	Ultrasound	Open surgery
Bassem Abou Hussein et al. [26]	47	M	Intestinal obstruction	Ultrasound and CT	Laparoscopy
Mohammad Masood et Al [27]	13	M	Acute Appendicitis	Ultrasound and X-RAY	Open surgery
Yukihiro Tatekawa [28]	11	M	Intestinal obstruction	X-RAY and CT	Laparoscopy
Jason Ray Bingham et al. [29]	29	M	Intestinal obstruction	CT	Laparoscopy
Levent Duman et al. [22]	1,3	M	Intestinal obstruction	Ultrasound and X-RAY	Open surgery
Lawrence et al. [30]	23	M	Acute appendicitis		Open surgery
Hamburger [31]	30	M	Acute appendicitis		Open surgery
Warren et al. [32]	12	M	Intestinal obstruction	CT	Open surgery
Mujica et al. [33]	68	M	Intestinal obstruction	X-RAY	Open surgery
Roberto Bini et al. [6]	50	M	Intestinal obstruction	X-RAY and CT	Open surgery
Colombo et al. [34]	65	M	Intestinal obstruction	X-RAY	Open surgery
Wagner et al. [35]	51	M	Intestinal obstruction	CT	Open surgery
	64	M	Intestinal obstruction	CT	Open surgery
Mosaddegh et al. [36]	20	M	Intestinal obstruction	X-RAY and CT	Open surgery
Daniel Yee Lee Ng et al. [37]	21	W	Intestinal obstruction	Ultrasound and CT	Open surgery
Cantrell et al. [38]	32	M	Intestinal obstruction	CT	Open surgery
Zello et al. [21]	8	M	Intestinal obstruction	X-RAY, Ultrasound and CT	Open surgery
Gupta et al. [24]	19	M	Intestinal obstruction	X-RAY	Open surgery
Peter J. Fagenholz et al. [39]	34	M	Intestinal obstruction	CT	Laparoscopy
Redmon et al. [40]	10	M	Intestinal obstruction	X-RAY and CT	Open surgery
Mathieu Halverson et al. [41]	25	W	Peritonitis	X-RAY	Laparoscopy converted
Levent Cankorkmaz [15]	2	M		X-RAY	Open surgery
Kıvılcım Karadeniz Cerit et al. [18]	10	M		X-RAY, Colonoscopy and Laparoscopy	Laparoscopy
Mauricio A. Escobar Jr. et al. [19]	2	M		X-RAY	laparoscopy converted
Gillian A. Willis et al. [16]	2,5	M	Peritonitis	X-RAY	Open surgery
A. Cotîrleå et al. [42]	37	M	Peritonitis	Ultrasound	Laparoscopy
Kim W Chan [43]	17	M	Peritonitis	X-RAY	Laparoscopy
Ioannis Dimitriou et al. [44]	64	M	Peritonitis	X-RAY	Open surgery
Yagci et al. [45]	30	M	Acute appendicitis	X-RAY and ultrasound	Open surgery
Henrik Christensen et al. [46]	24	M	Peritonitis	Laparoscopy	Laparoscopy
André Gonc ¸ alves et al. [25]	61	M	Peritonitis	CT	Laparoscopy
Nicolas J Mouawad et al. [47]	52	M	Peritonitis	X-RAY and ultrasound	Laparoscopy
Wong et al. [48]	21	W	Acute appendicitis		Open surgery
	49	W	Acute appendicitis		Open surgery
Bülent Hayri Özokutan et al. [17]	3	M	Abdominal pain	X-RAY	Open surgery
	5	M	Abdominal pain	X-RAY	Open surgery
Guillaume T et al	22	M	Intestinal obstruction	Ultrasound and CT	Open surgery

4. Risk factors

In our study, there were no reported psychiatric or gastrointestinal surgery histories as common risk factors for bezoar formation [4,5,9]. Dietary habits included excessive consumption of fruits or vegetables in 24.4 % of the cases and accidental ingestion of metallic objects in 17 % of the cases. Cases of metal object ingestion, such as batteries and coins, were observed in children, with the exception of one adult, whose ingestion was accidental. The remaining patients had no significant history that could explain the presence of a bezoar, which could be attributed to poor mastication or the ingestion of large amounts of poorly digestible food.

5. Epidemiology

We found 12 children and 29 adults among the cases, meaning that 29.3 % were children and 70.7 % were adults. This differs from the usual discovery pattern of Meckel's diverticulum, which is more common in childhood [10]. Therefore, foreign objects might complicate Meckel's diverticulum in adults. Our case involved a male patient and our review revealed a male predominance (85.4 %) in this pathological association. This has also been reported in many series of bezoars in the absence of Meckel's diverticulum [11,12]. The male/female ratio was 5.83, which is significantly larger than the 1.9 % reported for Meckel diverticulum [13]. The mean age was 28.17 years, ranging from 18 months to 66 years, more than 2.8 years reported the age of appearance of complications in Meckel's diverticulum [13].

6. Clinical presentation

The clinical presentation of this association was variable, with intestinal obstruction (51.21 %) being the most common. The Preoperative diagnosis was intestinal obstruction in 51.21 % of the cases studied, followed by appendicular peritonitis (21.9 %) and appendicitis (14.63 %). Approximately 7.32 % of the patients were asymptomatic, with investigations initiated due to a history of ingesting radiopaque material that did not progress on radiography. Appendicular disease is the most common differential diagnosis.

7. Radiological description

Radiography was performed in 46.34 % of cases, and Meckel's diverticulum was not diagnosed in any of these cases. Additionally, it revealed signs of occlusion in 26.82 % of the patients. Ultrasound was used in 24.39 % of the cases, but it did not detect any bezoars, and ultrasound was not very helpful for diagnosing Meckel's diverticulum [14]. However, this is more useful for children [13]. Its use was low in 25 % (n = 3) of children, possibly because half of them had swallowed a metal object such as a battery or coin, and doctors could track it with X-rays instead [[15], [16], [17], [18], [19]]. In the three cases in which ultrasound was used in children, two had intestinal occlusion, and one had peritonitis [[20], [21], [22]]. Perhaps doctors did not investigate for Meckel's diverticulum because it is not one of the most common causes of intestinal occlusion or peritonitis in children. Historically, CT scans have had limited success in diagnosing Meckel's diverticulum in the absence of complications because of the inability to differentiate Meckel's diverticulum from the normal small bowel [14]. In our study, diverticulum was identified in 16.66 % of CT scan cases, all of which presented with complications. Bezoars were identified in 50 % of patients who underwent CT, and complications were diagnosed in 88.9 % of the cases. The presence of a foreign body can complicate the interpretation of the CT scan, as the association of Meckel's diverticulum and a bezoar is rarely reported in the literature, and the appearance of Meckel's diverticulum on CT is polymorphic [7]. The exact nature of these objects was not established in any of the patients who underwent CT scans.

8. Treatments

Two therapeutic approaches were observed, with laparoscopy used in 34.15 % of cases and laparotomy in 65.85 % of cases. These two approaches in this situation are widely reported [[23], [24], [25]]. Laparoscopic treatment was successful in 85.71 % of the cases, with two cases initially used for diagnostic purposes. In 14.3 % of cases, laparoscopy was converted to open surgery due to technical difficulties associated with discovering intra-abdominal phlegmon and pelvic adhesions. In both open and laparoscopic surgeries, the diverticulum was resected and the bezoars were removed, as in our case. None of the described cases benefited from conservative or endoscopic treatments, despite success rates ranging from 71 to 100 % in gastrointestinal bezoars in the absence of Meckel's diverticulum [12]. This can be explained by the discovery of a complication in the majority of cases; the ileal site of the bezoar is difficult to access by endoscopy, and the majority of diverticula are discovered during surgery. Unlike the data available in the literature, we did not observe any cases of trichobezoar which is the second most common bezoar according to a certain author [4,11]. This can be explained by the absence of psychiatric patients in our study. Phytobezoar was the most commonly encountered type in this association, accounting for 56.1 % of the cases, followed by fish bones (12.2 %), chicken bones (9.75 %), batteries (9.75 %), and coins (7.31 %).

9. Limits of the study

The term “bezoar” does not refer to a specific object, and some bezoars are not directly cited as bezoars, limiting the search results. Another limitation was that not all languages were used to find studies in the research engine.

10. Conclusion

The association between a bezoar and Meckel's diverticulum can occur without any psychiatric disorders or previous gastrointestinal surgery. This condition typically presents as intestinal obstruction, but can also be asymptomatic. CT scans are valuable in detecting obstruction and foreign bodies, and when a foreign body does not progress on radiography, it may be trapped in the Meckel's diverticulum. Conservative treatment is not recommended for this combination, and both laparoscopy and open surgery are feasible treatment options. Phytobezoars were the most frequently encountered type of bezoar in this association.

Ethical approval

It was not required.

Sources of funding

The authors declare they have received no funding for the preparation of this document.

Author's contributions

Conception and study design: GT Soh, A Ndong.

Drafting of the article: GT Soh, A Ndong, AC Diallo and ML Diao.

Final approval: Jacques Noel Tendeng, Ibrahima Konate.

Guarantor

Guillaume Tcheutchoua Soh.

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Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Declaration of competing interest

The authors report no declarations of interest.